Provider Demographics
NPI:1588984710
Name:NICHOLSON, SUSAN (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-8242
Mailing Address - Country:US
Mailing Address - Phone:360-825-2558
Mailing Address - Fax:360-825-5941
Practice Address - Street 1:232 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-8242
Practice Address - Country:US
Practice Address - Phone:360-825-2558
Practice Address - Fax:360-825-5941
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00018674183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist